-
Red flags that suggest an organic cause to constipation
- 1)unintentional weight loss
- 2) >50
- 3) FHx Ca
- 4) rectal bleeding
- 5) Fe def anemia
- 6) elevated CRP
-
What are the requirements for the rome III criteria for functional constipation
- 1) symptoms > 3 mo; onset > 6mo
- 2) MUST include more than 2 of the following
- -straining
- -lumpy or hard stool
- -tenesmus
- -feels like anal blockage
- -manual removal of blockage
- -< 3 defecations a week
- 3) loose stools rarely present w/o use of laxatives
- 4) insufficient criteria for IBS
-
What is diarrhea?
- stool output > 200 g/day
- increased frequency > 3/day
- increased liquidity
-
What is the normal stool osmolality?
usually the same as the plasma osmolality (290-310)
-
What are the red flags in acute diarrhea?
- 1) high fevers/ systemic toxicity
- 2) severe abdo pain
- 3) blood/pus in stool
- 4) volume depletion
- 5) immunocompromised host
- - looks like you are thinking infection here.
-
What can you get from eating: poultry, seafood, cheese, canned foods, contaminated water
- poultry: shigella, salmonella
- seafood: salmonella
- cheese: listeria
- canned food: clostridium
- water: giardia, norwalk
-
When are stools pale, oily, malodorous, difficult to flush?
When there is malabsorption of fat
-
What is a dermal sign of celiac's disease?
dermatitis herpetiformis (itchy rash)
-
disease sequence of adenoma carcinoma
normal->hyperprolif epithelium -> adenoma -> carcinoma
-
What are the 3 criteria for HNPCC (hereditary non-polyposis CRC)?
- 1) three family members (2 first degree) affected with HNPCC
- 2) at least 2 successive generations affected
- 3) one relative diagnosed at <50
-
What are the chronic symptoms of colo-rectal cancer?
- -bleeding
- -change in bowel habit
- -non-spec. abdominal pain
- -anemia
- -wt loss
- -other symptoms from mets
-
What are the top five hits on the DDx for IBD?
- 1) infectious etiologies
- 2) IBS
- 3) appendicitis
- 4) diverticulitis
- 5) Ca
-
When should you do surgery in Crohn's?
- 1) complications: fix strictures, fistulas, perforations
- 2) medically refractory disease
IMPORTANT TO MEDICALLY CONTROL, OTHERWISE THE PATIENT WILL LIKELY NEED SURGERY!!
-
When to do surgery for UC?
- 1) medically refractory disease
- 2) complications: perforation, toxic megacolon, cancer
-
What are some questions you should ask yourself when you have a patient with jaundice?
- 1) acute vs chronic (>6mo)
- 2) hepatocellular, cholestatic, or vascular
- 3) systemic disorder or a primary liver disorder?
- 4) any complications that need investigation or treatment?
-
What are the big 7 things you test for liver function?
- Hepatocellular enzymes
- -AST: RBC, muscle, liver
- -ALT: liver
- Cholestatic enzymes
- -ALP: bone, placenta, liver
- -GGT: Liver
ABC: Albumin, Bilirubin, Clotting (INR)
-
What are the 3 types of hepatitis
- 1) fulminant: NORMAL liver with ACUTE injury developing hepatic encephalopathy within 8 weeks
- 2) Acute hepatitis
- 3) Chronic hepatitis: longer than 6 months
-
What specific test would you use to determine autoimmune hepatitis?
- ANA - anti-nuclear Ab
- anti smooth muscle Ab
-
What are the top 8 on the differential for cirrhosis?
- 1)Viral: Hep B, C
- 2) Autoimmune: Primary Biliary cirrhosis, autoimmune hep
- 3) Inherited: Wilson's, hemochromatosis, alpha1- AT
- 4) alcohol
- 5) Cardiac
- 6) NAFLD
- 7) Drugs/Toxins
- 8) Idiopathic
-
What are the limits for a good or bad MELD score? What is the score based on?
based on: creatinine, INR, bili
-
What is charcot's triad?
fever, pain, jaundice
looks for in acute cholangitis and choledocholithiasis
-
What are the risk factors for cholangiocarcinoma?
- -PSC
- -choledochal cysts
- -parasitic infection
- -hepatolithiasis
-
Where would you expect to see a positive anti-mitochondrial Ab test?
in primary biliary cirrhosis (PBC)
-
What are the indications for testing in hemochromatosis?
- 1) Liver disease
- 2) abnormal LEs
- 3) DM
- 4) arthropathy
- 5) heart disease
- 6) impotence
- 7) FHx
-
Indications to test for Wilson's
- 1) unexplained LD in young person
- 2) hemolysis
- 3) neurological disease in young person
- 4) KF rings
- 5) affected siblings
-
Indications to test for alpha1 AT
- 1) neonatal hepatitis
- 2) chronic hepatitis
- 3) cirrhosis
- 4) HCC
- 5) precocious emphysema
-
What shoiuld you give ALL patients with cirrhosis who present with GI bleeds
Abx (at greater risk of infection)
-
What are the precipitants of hepatic encephalopathy?
- 1) infection
- 2) GI bleeding
- 3) high protein load (hold off the burgs)
- 4) HCC
- 5) Constipation
- 6) Drugs (alcohol, narcotics, sedatives, etc)
- 7) Electrolyte imbalance
See dirty mnemonic in notes
-
When would you expect to see elevated alpha-fero protein?
in HCC
-
Describe the Grey-Turner's and Cullen's signs
- Both are for acute panc.
- Grey- Turner's: bruising on the flanks
- Cullens: bruising around the umbilicus (C for Central)
-
What is the rule of S's for pancreatic psuedocysts?
- Treat when:
- -older than six weeks
- -bigger than six cm
- -symptomatic
-
Indications for liver transplant
- -end stage liver disease
- -acute liver failure
- -malignancy?
-
What wheels start falling off at end-stage liver disease?
- -variceal bleeds
- -encephalopathy
- -infection
- -renal/fluid/ascites
-
What are the absolute contraindications in liver transplants
- -active sepsis
- -extra-hepatic malignancy
-
If you see a patient present with jaundice, but all liver function tests are normal except for a high unconjugated bili, what should you be thinking?
Gilbert's syndrome (decreased activity of glucoronyl transferase)
-
What are the Abs you expect to see in someone with:
1) Primary biliary cholangitis?
2) autoimmune hepatitis?
- 1) antimitochondrial abs
- 2) anti smooth muscle Abs
-
What protein do you see elevated in HCC?
alpha fetoprotein
-
What do you expect to happen to the amylase and lipase levels in acute pacnreatitis? Chronic?
- acute: both increased
- Chronic: both increased to normal (due to level of destruction?)
-
What is the inheritance of Hemochromatosis, Wilson's, and alpha1 AT?
- Hemo: AR
- Wilsons: AR
- Alpha1- AT: co-dominant (the ZZ allele is the bad one)
-
What is the type of cirrhosis that most often progresses to HCC?
cirrhosis due to hemochromatosis
-
When is PPI prophylaxis indicated?
if they are at high risk development of ulcers
-
Describe what an elevated stool osmolality gap is/means
difference between measured stool osmolality and 2x[Na]+[K] which is the calculated osmolality
In osmotic diarrhea, measured is greater than calculated. Therefore there is something else (e.g. lactic acid, that is pulling water in)
-
What are the vit K dependent factors?
1(0)972 olympics Canada vs Soviet union
Factors X, IX, VII, II, protein C, protein S
-
Describe the graded therapy for Crohn's disease
-
What biliary disease is associated with UC?
PSC
-
5 causes of constipation
- DOPED
- Drugs
- Obstruction
- Pain
- Endocrine
- Depression
-
What is the only clotting factor not produced in the liver?
factor VIII
-
You have elevated transaminases, what should you think if you have:
1) ALT>AST
2) AST > ALT
3) AST/ALT >2
- 1) ALT>AST: most causes of hepatitis
- 2) AST > ALT: alcoholic liver disease or other causes of cirrhosis
- 3) AST/ALT >2: alcohol
-
List 7 complications of cirrhosis
- VARICES
- Varices
- Anemia
- Renal Failure
- Infection
- Coagulopathy
- Encephalopathy
- Sepsis
-
Three things you can use to manage portal hypertension
- beta blockers
- nitrates
- shunts
-
What etiologies of ascites would you be thinking if the serum-ascited albumin gradient was
1) > 11 g/L
2) < 11 g/L
- 1) high: portal hypertension related (because hydrostatic pressure is driving it)
- 2) low: non-portal hypertension causes
-
What does it mean when a jaundiced patient has:
1) high conjugated billi
2) high unconjugated billi
- 1) high conjugated billi: there is some problem after the billi is conjugated in the hepatocytes. problem with excretion
- 2) high unconjugated billi: overproduction (e.g. hemolysis); decreased hepatic uptake; decreased conjugation (e.g. gilberts)
-
How can ERCP (endoscopic retrograde cholangopancreatography) differentiate primary biliary cirrhosis from PSC
- PBC: no narrowing
- PSC: narrowing of intra and extrahepatic ducts
-
What is squamous cell esophageal cancer associated with?
smoking and drinking
-
Why does esophageal cancer metastesize easily?
because it lacks a serosa
-
How does gastritis cause B12 deficiency?
lack of intrinsic factor
-
Which LN is enlarged in gastric cancer
Virchow's node (left supraclavicular)
-
What happens to the pain post-prandially in:
1) gastric ulcer
2) duodenal
- 1) Gastric is Greater
- 2) Duodenal Decreases
-
What is the most common bacterial etiology of diarrhea?
campylobacter
-
What is NOT a risk factor for peptic ulcer disease?
STRESS!
-
What disease is dermatitis herpetitiformis associated with? How do you test?
celiac disease. test serum tissue transglutaminase
-
What is the most common cause of acute lower GI bleeding in a patient >40?
diverticulosis
-
If you see >250 PMN's in the ascitic fluid what should you be thinking?
spontaneous bacterial peritonitis
-
Describe:
0) Cholelithiasis
1) biliary colic
2) Cholecystitis
3) Cholangitis
4) choledocholithiasis
- 0) Cholelithiasis: stone floating innocently in the gallbladder
- 1) Biliary colic: stone goes against the cystic duct after a meal and dislodges itself in 4-8 hours.NOT tender, visceral pain
- 2) Cholecystitis: stone impacted in cystic duct and stays. NOW pain localizes and is tender.
- 4) Cholangitis: complete obs of CBD AND infection. life threatening.
- 5) choledocholithiasis: Stones in common bile duct, obstructive jaundice and pruritis.
-
Extra-intestinal manifestations of IBD
- A PIE SAC
- Aphtous ulcers
- Pyoderma gangrenosum
- Iritis
- Erythema Nodosum
- Sclerosing cholangitis (UC only)
- Arthritis
- Clubbing
-
What does a positive HBsAg and HBsAb mean?
- HBsAg means that there is an active infection (chronic or acute)
- HBsAb means that there is immunity to HBV (natural or vaccine)
|
|